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Updated: Jul 8 2022

Cerebral Palsy - Upper Extremity Disorders

Images hand.jpg in palm.jpg
  • summary
    • Upper Extremity Disorders in Cerebral Palsy are caused by spasticity and can take the form of shoulder, elbow, wrist, or hand contractures. 
    • Diagnosis is made clinically with restriction or limitations in motion of the shoulder, elbow, wrist, hand or fingers, secondary to spasticity. 
    • Treatment can range from bracing to surgical soft tissue release or osteotomy depending on severity of deformity, limitations in ability to maintain hygiene, and functional deficits. 
  • Epidemiology
    • Demographics
      • typically seen in in patients with hemiplegia and quadriplegia
  • Etiology
    • See Cerebral Palsy General
    • Characteristic deformities include
      • shoulder internal rotation contracture
      • forearm-pronation / elbow flexion deformity
      • wrist-flexion deformity
      • thumb-in-palm deformity
      • finger-flexion deformity
    • Treatment of upper extremity conditions can be divided into
      • hygienic procedures
        • indicated to maintain hygiene in patients with decreased mental and physical function
      • functional procedures
        • indicated in patients with voluntary control, IQ of 50-70 or higher, and better sensibility
  • Shoulder IR Contracture
    • Overview
      • characterized by glenohumeral internal rotation contracture
    • Treatment
      • shoulder derotational osteotomy and/or subscapularis and pectoralis lengthening with biceps/brachialis lengthening capsulotomy
        • indications
          • severe contracture (>30 degrees) interfering with hand function
  • Forearm-Pronation / Elbow-Flexion Deformity
    • Overview
      • usually consists of a combination of a
        • forearm pronation deformity and
        • elbow flexion contracture
    • Treatment
      • lacertus fibrosis release, biceps and brachialis lengthening, brachioradialis origin release
        • indications
          • elbow flexion contracture
      • pronator teres release
        • indications
          • forearm pronation deformity
        • technique
          • transfer to an anterolateral position
        • complication
          • supination deformity
            • this is less preferable than a pronation deformity
      • FCU transfer
        • transfer of the FCU to the ECRB
          • indications
            • another option for pronation deformity
  • Wrist-Flexion Deformity
    • Overview
      • wrist is typically flexed and in ulnar deviation
      • associated with weak wrist extension and pronation of the forearm
    • Phyiscal exam
      • Assessing a wrist flexion contracture is done by extending all the fingers with the wrist in maximal flexion, then extending the wrist. The degree to which the wrist cannot fully extend is the Volkmann angle.
    • Treatment
      • FCU or FCR lengthening
        • indications
          • when there is good finger extension and little spasticity on wrist flexion
      • Tendon Transfers (FCU to ECRB or FCU to EDC transfer)
        • indications
          • as a functional procedure in patients with voluntary control, IQ of 50-70 or higher, and better sensibility
          • significantly improved long-term function when compared to nonoperative modalities (i.e. botulinum/therapy) alone 
          • alternative includes ECU to ECRB transfer (avoids transferring a spastic FCU that could result in hyperextension deformity after transfer)
          • technique
            • with good grasp ability
              • transfer FCU to EDC
            • with poor grasp ability
              • transfer FCU to ECRB
      • flexor release
        • indications
          • weakening of the wrist flexors
        • technique
          • release of the flexors of the wrist and pronator teres from the medial epicondyle
      • wrist arthrodesis
        • indications
          • to improve hygiene and function in patients with non-supple contractures who lack volitional control of the wrist/hand 
  • Thumb-in-Palm Deformity
    • Introduction
      • flexed thumb into palm prevents grasping and pinching activities
        • can preclude appropriate hygiene
    • Classification (House)
      • House Classification
      • Type
      • Characteristics
      • Treatment
      • Type I
      • 1st metacarpal adduction contracture
      • Adductor release, possible 1st dorsal interosseous release
      • Z-plasty of the skin contracture in the 1st web
      • Type II
      • 1st metacarpal adduction contracture + contracture of the MP joint
      • Adductor release
      • Release of FPB
      • Type III
      • 1st metacarpal adduction contracture +unstable or hyperextendable MPJ
      • Adductor release
      • Fusion or capsulodesis of the MP joint
      • Type IV
      • 1st metacarpal adduction contracture + MPJ and IPJ flexion contractures
      • Adductor release
      • FPB and FPL release or lengthening
    • Treatment
      • release of the adductor pollicis, transfer of tendons, and stabilization of the MCP joint
        • indications
          • as a functional procedure in patients with voluntary control, IQ of 50-70 or higher, and better sensibility
  • Finger-Flexion Deformity
    • Introduction
      • a result of intrinsic muscle tightness along with extrinsic overpull of the finger extensors
    • Treatment
      • swan-neck deformities can often be helped with correction of the wrist flexion deformity
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